Is shock trauma moving in the right direction?

Mary Jo Warthen

IT WAS the spring of 1972. The stuffed green peppers in th oven filled the house with their delectable aroma. I glanced out the kitchen window, expecting my husband momentarily.

Suddenly a crash, a crying child. I ran to the living room and saw the broken glass from the storm door on the carpet. Only a jagged shard remained in the door. Tears streamed down my son's cheeks.

A quick check. No blood. Relief. Yet, I couldn't console him. He was sobbing uncontrollably. I checked again and noticed a bulge under his shirt. What's this? I lifted the fabric carefully and saw a small marbled ball like the ones in a set of jacks. Where did he get this? Then it came to me: This was a ball of intestine. The vicious shard had punctured his abdomen. "Call an ambulance!" I screamed to my neighbor, who had started toward my house.

I lifted Jeff gently onto my lap and stroked his blond hair. "It's OK," I told him, desperately hoping I was right. I heard the distant siren become louder, and then the ambulance screeched into the driveway. With what seemed a single motion, one of the paramedics was through the door and kneeling on the floor next to us. He carefully lifted my son's shirt and called to his partner: "There's nothing I can do for him. See if the chopper's close by." His voice betrayed just a hint of panic.

There's nothing I can do for him?

Thank God, the paramedic had made contact. When we reached Liberty Road, we saw that the helicopter had landed. With utmost efficiency, the well-practiced team lifted Jeff out of the ambulance and into the chopper. As I watched them lift off with my son, I felt my heart was being torn from my chest.

I don't think I breathed as the next several hours sped by. The police rushed me to University Hospital. By the time we arrived, the shock trauma team had stabilized Jeff and prepped him for surgery. In a daze, I signed the consent forms and sat on the edge of a leather sofa in a nondescript lobby. Three hours later, the surgeon emerged from the elevator. "He's going to be all right!" At that moment I discovered what it meant to be "weak with relief."

Less than six hours after the accident, Jeff was in the recovery room. The shock trauma surgeons had opened his abdomen, unpacked and inspected his bowel for perforations (none were found), sutured a laceration in his liver, repacked his bowel and closed his abdomen. Dr. R Adams Cowley's fledgling Maryland Shock Trauma Center had saved my son's life.

Now, 20 years later, this same shock trauma unit is embroiled in controversy because of a policy change initiated by its new director, Dr. Kimball Maull. Dr. Maull, who arrived in February, opened the center to patients with non-life-threatening injuries. This produced endless turmoil. First, three of University Hospital's trauma specialists were fired for (among other things) questioning the new policy, which they fear will jeopardize the quality of patient care (although it will supposedly improve shock trauma's finances).

Then shock trauma's chief neurosurgeon filed a $6 million lawsuit alleging he is being wrongly forced out of his job because of differences with Dr. Maull over treatment of patients. In the midst of all this, Dr. Maull has stepped back from the direct supervision of shock trauma, although he continues to oversee the statewide emergency medical system.

Everyone agrees that we need to preserve the excellence of patient care, which has been synonymous with the Maryland Shock Trauma Center since its inception. Yet, everyone also realizes that in this tight economy, bills still have to be paid.

The story of what happened to my son throws some light on the situation. Like my son, victims of life-threatening injuries need immediate, intensive, efficient care by trained trauma professionals. When a victim is admitted, everyone in the unit focuses on stabilizing and treating him or her. Confronted with several accident victims, doctors treat the most seriously injured first. Wouldn't those with lesser injuries be better served in an emergency room where they would not have to vie for treatment with the critically injured?

But even if we could concede that patient care wouldn't be jeopardized, an important question remains: Do we want patients treated at shock trauma who don't need its expensive, specialized services?

For years doctors have been concerned with a similar question. Poor people in Baltimore and most other big cities use hospital emergency rooms in place of "family" doctors. This not only ties up the resources of the emergency room, but it also increases the overall cost of health care. The simple fact is that it costs more to treat a patient in an emergency room than in a doctor's office, and it costs more to treat a patient in shock trauma than in an emergency room.

So, while using shock trauma to treat patients with mid-level and minor injuries improves the financial performance of the center, it also increases the cost of medical care in the long run.

This is a nation in a health-care crisis. At least one state has been forced to consider rationing health care to Medicaid patients because of lack of funds. Health-care issues such as cost containment will loom large in this year's presidential elections.

In a country where our goal should be to do whatever is feasible to improve the quality of health care while reducing health-care costs, isn't shock trauma moving in the wrong direction?

Mary Jo Warthen is administrative assistant at Mount de Sales Academy in Catonsville and the mother of three children. Jeffrey Warthen is a 24-year-old electronics engineer.